Failure to Implement After-Hospital Visit Care Instructions
Penalty
Summary
The facility failed to ensure that after-visit care instructions from hospital transfers were implemented for two residents who had recently undergone surgical interventions for femoral fractures. Both residents were admitted with specific aftercare instructions documented in their After Visit Summaries (AVS), including activity restrictions, sleeping positions, use of ice and elevation, and wearing compression stockings. However, upon review, there were no corresponding physician orders or care plan interventions addressing these instructions, such as sleeping precautions, ice application, or limb elevation. Interviews with nursing staff confirmed that such instructions should be entered into the care plan and physician orders, and that any treatments like ice or elevation would typically be documented in the Treatment Administration Record (TAR) or Medication Administration Record (MAR) after obtaining a physician's order. Further, one resident reported only occasionally receiving ice and was unaware of the need for leg elevation, indicating a lack of communication and implementation of the prescribed aftercare. Staff interviews revealed that the admitting nurse is responsible for entering aftercare instructions into the care plan and obtaining necessary physician orders, but this process was not completed. The Director of Nursing confirmed that AVS orders should be implemented and reflected in the care plan. The facility's policy requires comprehensive care plans to be developed with resident-specific interventions, but this was not followed for the residents in question.